Employment Application Form

Part 1: Personal Information

Position applied for (first preference)
Position applied for (second preference)
Desired rate of pay
What is your preferred shift?
Please list any shift you are not willing to work.
Are you willing to work overtime as required?
How did you learn about us?
Name (first, middle, last)
Address (number, street, city, state, zip)
Home phone
Cell phone
Email
Are you at least 18 years old?
Are you legally eligible for employment in the United States?
Are you willing to take a pre-employment drug test?
Do you expect to be engaged in any other business or employment?
If yes, state the nature of the business and the amount of time it takes.

Equal Employment Opportunity Information

Bethany House Services is committed to offering equal opportunity in employment to all employees and applicants for employment. BHS ensures equal employment opportunity without discrimination or harassment on the basis of race, religion, color, gender , age national origin, disability, veteran status, sexual orientation, marital status, gender identity or expression, citizenship, genetic information or any other characteristic protected by law. BHS prohibits any such discrimination or harassment. This policy applies to all terms, conditions, and privileges of employment, including hiring, introductory period, training and staff development, promotion, transfer, compensation, benefits, educational assistance and termination.

Gender:
Over 40:
Disabled:
Race:
HispanicWhite (Not Hispanic or Latino)Black or African American (Not Hispanic or Latino)Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)Asian (Not Hispanic or Latino)Native Indian or Alaskan NativeTwo or More Races (Not Hispanic or Latino)

Part 2: Educational Background

High School

School name
Location
Did you graduate?
Field of study

Business or Trade School

School name
Location
Did you graduate?
Field of study

College or University

School name
Location
Did you graduate?
Field of study

Post-Graduate

School name
Location
Did you graduate?
Field of study

Other

School name
Location
Did you graduate?
Field of study

Part 3: Criminal History

Please complete the following if you ever pled guilty to or been convicted of any crime, misdemeanor or felony. If none, write "none".

Date of conviction
City and State
Charge
Disposition

Part 4: Employment History

Please list name, address, and phone number of previous employers with most recent employer first. Also, explain all gaps in employment in the "Additional Information" field at the bottom of this form.

Employer Name
Employer Address (Street, city, state, and zip code)
Employer Phone
Position Title
Dates employed
to
Supervisor Name
Duties
Reason for leaving
Employer Name
Employer Address (Street, city, state, and zip code)
Employer Phone
Position Title
Dates employed
to
Supervisor Name
Duties
Reason for leaving
Employer Name
Employer Address (Street, city, state, and zip code)
Employer Phone
Position Title
Dates employed
to
Supervisor Name
Duties
Reason for leaving
Employer Name
Employer Address (Street, city, state, and zip code)
Employer Phone
Position Title
Dates employed
to
Supervisor Name
Duties
Reason for leaving

Part 5: References

Please list two business references and one personal reference.

Name
Title
Company Name and Address
Telephone
Email address
Dates Known
Name
Title
Company Name and Address
Telephone
Email address
Dates Known
Name
Title
Company Name and Address
Telephone
Email address
Dates Known

Part 6: Additional Information

Please list all computer software programs you are familiar with and rate your proficiency level for each (beginning, intermediate, or advanced).

Please list any additional employment, experience, or skills relevant to the position for which you are applying. (Include all gaps in employment.)

Please provide details regarding criminal history.

Verification and Signature

Please read carefully before signing your signature.

I certify that the forgoing responses to each question are true and complete to the best of my knowledge and I have not knowingly withheld any requested information which would affect my consideration for employment. I understand that false or incomplete information may result in immediate dismissal. I agree to permit Bethany House to contact my past employers, schools and references, and further agree not to hold anyone liable for information received. I understand that my employment would be for an indefinite period and agree that if hired, my employment is “at-will” and either Bethany House Services or I may terminate the relationship at any time, ant that this employment application does not constitute an employment contract.

I agree not to commence any action or suit related to my application or prospective employment with the Company: (1) more than six months after the termination of my prospective employment, if the action or suit is related to the termination of my employment, or (2) more than six months after the event or occurrence on which my claim is based, if the action or suit is based on an event or occurrence other than the termination of my employment. I agree to waive any statute of limitations that is contrary to this Paragraph. I understand and agree that I can still file a charge with or participate, testify, or assist in any investigation, hearing, or other proceeding before any federal, state, or local government agency. To the extent I file a charge(s) with any federal, state, or local government agency, I agree that I am required to file the charge(s) within the statutory statute of limitations applicable to such charge(s).